Goals of care discussions capture patient-defined values in cancer care

CHICAGO — Patient-defined value is the key ingredient missing from a variety of frameworks in cancer care, Janet Freeman-Daily, said during a keynote address at International Association for the Study of Lung Cancer Multidisciplinary Symposium in Thoracic Oncology.

“Clinical pathways can bring evidence-based options to shared decision-making, but the patient must provide the definition of value,” Freeman-Daily, a lung cancer survivor, said during the keynote address. “The patient must have the final word on how they want to experience their remaining time, however long that may be. No clinical pathway, clinician or health care system should make a decision for a patient on whether length of survival is more important than quality of life.”

The Agency for Healthcare Research and Quality SHARE approach recommends clinicians aim to do the following:

seek the patient’s participation;
help the patient explore and compare treatment options;
assess the patient’s values and preferences;
reach a decision with the patient; and
evaluate the patient’s decision.

Still, a majority of physicians admitted to not following these approaches.

In a variety of surveys, patients tended to value quality of life, length of life and the impact of cancer on their families as the highest priorities; however, impacts of side effects such as physical, cognitive, emotional and functional impacts in cancer care varied by patient.

In addition, a majority of patients demonstrated a desire for shared decision-making, yet most did not understand the intent or likely outcomes of treatment.

In particular, 72% of patients said they would want their doctor to discuss their prognosis with them, but only 17% reported actually being told their prognosis. Eight percent of those surveyed showed they would like to discuss end-of-life care, but only 7% reported having this conversation with their physician.

Therefore, Freeman-Daily advocated for the use of goals of care discussions.

“Goals of care discussions help providers capture patient-defined values,” she said. “They can also improve outcomes and reduce costs. Goals of care discussions are essential in helping both patients and providers capture patient-defined values and identify what matters most to the patient.”

The American College of Physicians High-Value Care Task Force found evidence in support of physicians having early discussions with patients with serious illnesses using goals of care discussions.

Evidence demonstrated these discussions conferred benefits to patient outcomes with no harmful side effects; they helped patients define what matters to them and helped the clinician tailor treatment to meet those preferences and values; and they reduced the use of aggressive interventions to seriously ill patients and, as a result, reduced costs.

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In addition to goals of care discussions, Freeman-Daily suggested the use of outside resources such as:

The Institute of Medicine’s recommended questions;
VITALtalk, designed to offer resources for physicians, including suggested questions for goals of care discussions;
Ariadne Lab-offered resources on serious illness care; and
The Conversation Project, designed to emphasize conversation on values.

“The current value frameworks for cancer do not include patient-defined value, and yet it is an essential part of shared decision-making and cost-effective treatment choices,” Freeman-Daily said. “Goals of care discussions can help capture patient values and preferences and reduce costs. And tools now exist to help in those discussions.” – by Kristie L. Kahl

Reference:

Freeman-Daily J. Value frameworks in cancer care: A patient perspective. Presented at International Association for the Study of Lung Cancer Multidisciplinary Symposium in Thoracic Oncology; Sept. 14-16, 2017; Chicago.

Disclosure: HemOnc Today could not confirm Freeman-Daily’s financial disclosures at the time of reporting.